Is there any benefit to giving midazolam (a benzodiazepine) for a patient presenting with chest pain, potentially related to acute coronary syndrome?

Midazolam Has No Role in the Management of Chest Pain

Midazolam should not be given for chest pain, as it is not recommended in any major guideline for acute coronary syndrome or chest pain evaluation and may cause harmful hemodynamic effects that obscure the clinical picture.

Why Midazolam is Not Indicated

The comprehensive AHA/ACC/CHEST/SAEM guidelines for chest pain evaluation make no mention of benzodiazepines or sedatives in the management algorithm 1. The focus of acute chest pain management is on:

• Rapid diagnosis through ECG within 10 minutes 1
• Pain relief with appropriate agents (not benzodiazepines) 1
• Early risk stratification to identify life-threatening conditions 1, 2
• Immediate reperfusion therapy when indicated 1, 2

Potential Harms of Midazolam in Chest Pain

Hemodynamic Concerns

Midazolam causes significant cardiovascular depression even in controlled settings, with documented effects including 3:

• Mean arterial pressure reduction of 17%
• Cardiac index reduction of 9%
• Capillary pressure reduction of 23.5%
• Heart rate reduction of 9%

These hemodynamic changes can mask critical signs of cardiogenic shock, worsen hypotension in acute MI, and interfere with accurate risk assessment 3.

Diagnostic Interference

Sedation with midazolam creates multiple problems 1:

• Obscures symptom progression, which is critical for risk stratification
• Impairs patient communication during serial assessments
• Delays recognition of clinical deterioration such as worsening ischemia or development of complications
• Interferes with shared decision-making, which is a Class I recommendation for chest pain evaluation 1

What Should Be Done Instead

For Anxiety-Related Chest Pain

Even when anxiety is suspected as the cause, the priority remains cardiac exclusion 4:

• Obtain troponin levels immediately - a normal ECG alone is insufficient, as 5-40% of acute MI patients have normal initial ECGs 4
• Provide definitive reassurance once cardiac workup is negative 4
• Refer for cognitive-behavioral therapy, which shows 32% reduction in chest pain frequency over 3 months 4

Do not use benzodiazepines as a diagnostic or therapeutic shortcut - this delays appropriate psychiatric treatment and reinforces illness behavior 4.

For Pain Relief in Confirmed ACS

The European Society of Cardiology guidelines emphasize pain relief as an aim of management but specify appropriate agents 1:

• Nitroglycerin for ischemic pain
• Morphine if pain persists (though use cautiously)
• Oxygen if hypoxemic

Sedatives like midazolam are not part of the pain management algorithm 1.

Critical Pitfalls to Avoid

• Never delay ECG or troponin testing to "calm the patient" with sedation 1, 2
• Never assume chest pain is anxiety-related without completing cardiac workup, especially in women who are at higher risk of missed ACS 4
• Never use sedation as a substitute for proper risk stratification and definitive diagnosis 1
• Remember that consultation delays increase mortality - adding sedation creates another unnecessary delay 2

The Bottom Line

There is no evidence supporting midazolam use for chest pain, and substantial evidence suggests it may cause harm by masking symptoms, causing hemodynamic instability, and delaying appropriate diagnosis and treatment 1, 2, 3. Focus instead on rapid ECG acquisition, troponin measurement, and appropriate risk stratification per established guidelines 1, 2.